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insertion area. IV start kits are available that

VASCULAR ACCESS usually include all of these items.
● Stable intravenous (IV) access is necessary for ● Choose the gauge of the IV indwelling catheter.
contrast media administration. ● The anticipated flow rate of the contrast
○ In many instances, the IV line must be injection should be appropriate for the gauge of
placed while the patient is in the CT the catheter used.
department. ● Although 22-guage catheters may be able to
○ In other instances, patients arrive in the CT tolerate flow rates up to 5mL/s, a 20-gauge or
department with IV access. larger catheter is preferable for flow rates of 3
● In addition to standard indwelling peripheral mL/s or higher.
catheters (e.g., BD Angiocath, BD Medical, ● Select two different gauges of catheter, usually a
Franklin Lakes, NJ), patients may arrive with 22-gauge and 20-gauge, to make it easier to adapt
central venous access devices (CVADs). to the size of the peripheral vein chosen.
○ Although CVADs are not optimal for ● After arranging the IV supplies, interview the patient
contrast administration, in some cases to once again verify their identity and to answer any
they are the only option available. additional questions they may have
○ Therefore, CT technologists must have a CHOOSING THE SITE
working knowledge of the different types of
CVADS, including when and how they can ● The superficial venous anatomy of the upper
be used to administer iodinated contrast extremity allows many choices of a particular vein in
media. which a peripheral IV line can be placed
● An antecubital or large forearm vein is the preferred
STARTING A PERIPHERAL INTRAVENEOUS LINE venous access site when a mechanical injector is
● Starting an IV line requires a venipuncture used.
technique, in which a needle is inserted into a vein. ○ However, if the patient will be required to
● Before beginning the process the basic consent of lift the arms for scanning, it is important
the patient is obtained by explaining the that the patient is able to keep the arm
procedure and asking whether the patient consents. somewhat straight while above the head.
● Aseptic technique must be observed for all ● Bending at the IV site may kink the IV line and
intravenous procedures. cause it to fail during the injection of contrast media.
● For the protection of the patient and the healthcare If a more peripheral site, such as the hand or wrist,
worker, standard precautions must be strictly is used with a smaller gauge catheter, it may be
adhered to necessary to limit the flow rate to 2.0 mL/s or less.
● An indwelling catheter set with a flexible plastic PLACEMENT
cannula should be used whenever a mechanical
injector will be used for contrast media injection. ● After assembling the supplies, verifying the patient's
● The use of metal needles (i.e Butterfly infusion sets identity, and selecting the site, venipuncture can be
or straight needles) should be avoided in initiated.
conjunction with mechanical "power" injection as ● Apply a tourniquet about 2 inches proximal to
they may contribute to contrast media extravasation the chosen site. If the vein selected for placement
and patient injury. does not adequately distend, place a second
● Whenever possible, catheters, and other ancillary tourniquet just above the first and hang the arm
components in the contrast fluid path to the patient, below the level of the patient's heart.
should be specifically designed for compatibility or ● Wearing gloves, prepare the area selected for
have pressure and flow rate compatibility with the puncture with the applicator. Use a circular pattern
parameters that will be programmed for the power starting in the center and working outward 2 to 3
injection. inches.
● Allow the area a few moments to dry. Never blow
An indwelling catheter set typically consists of: on the site!
● a plastic catheter and hub, ● Hold the catheter, bevel upward, along the course
● a beveled needle and hub, of the vein from peripheral to central and at a 30°
● a bevel position indicator, and to 45° angle to the skin with one hand, and gently
● flashback visualization chamber pull the skin in the direction opposite to that of the
● The visualization chamber may contain a reverse needle being placed with the other hand.
spring load to automatically retract the needle when ○ This will facilitate entry through the skin.
it is removed from the catheter. ● Forward resistance is lost once the skin is
● Regardless of the particular brand of the indwelling penetrated.
catheter, the basic design is the same. ○ Decrease the angle of the needle and
● A metal needle, ranging in gauge from 25 to 14 direct it toward the vein.
(the smaller the number, the larger the bore of the ○ As soon as the needle enters the vein,
needle), has a tight-fitting plastic catheter placed blood will enter the flashback visualization
over it. chamber.
● The catheter is slightly shorter than the needle, so ● Next, advance the needle just a few millimeters into
that a short segment of the needle protrudes the vessel.
beyond the catheter ○ Advance the catheter hub slightly away
from the needle hub and release the
SUPPLIES NEEDED tourniquet set.
● Collect the needed supplies before beginning ● Continue to advance just the catheter hub three-
venipuncture, including a tourniquet, tape, sterile quarters of the way over the needle, but not
gauze, a small cotton ball, saline (in either a completely off of the needle.
syringe or a bag with an IV drip set), disposable ● Place a piece of gauze under the end of the
gloves, and applicators for preparation of the catheter to absorb any small volume of blood that
might be lost.
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● Hold direct pressure over the vein just proximal to ● Before injecting contrast media, ensure the patency
the insertion site, release the needle from the of the line by using a small syringe to flush the line
catheter (setting the needle in plain sight), and with 2 to 5mL of saline.
attach the saline-filled syringe or connector to the ● Because of the potential for chemi- cal
catheter hub. incompatibility, contrast media should not be mixed
● After flushing the IV with the saline to demonstrate with, or injected in, IV administration lines contain-
the patency of the IV line, cover the site (except the cations are being given through the port at the time
end of the connector) with sterile covering. If there of the examination, an additional bag of saline can
is difficulty in threading the catheter through the be hung (i.e., "piggy-backed") and connected to an
vein, try to continue threading the catheter while open port on the existing IV tubing.
flushing with saline. ● Existing medications should be turned off only long
● This procedure often allows the catheter to pass enough to complete the contrast injection. The line
along the inside lumen without further difficulty. should be flushed with saline solution before the
● Secure the connector to the arm by placing a strip contrast injection.
of tape beneath the catheter and then bring it ● Once completed, the line should once again be
forward, crossing over the connector and onto the flushed with saline solution before medications are
skin. restarted. It is important to restart the patient's
○ Secure any extension tubing to the arm medication at the identical preexamination rate.
with paper tape.
USING A CENTRAL VENOUS ACCESS DEVICE
○ When using any sort of extension tubing
set, ensure it is rated for use with power ● A CVAD is a venous catheter designed to deliver
injectors or has been rated to tolerate the medications and fluids directly into the superior
flow rates and pressures created with vena cava (SVC), inferior vena cava (IVC), or right
power injections. atrium (RA).
● Next, dispose of the sharp needle in the appropriate ● They provide a painless way of drawing blood or
disposal unit and clean the venipuncture area of delivering medications to a patient's bloodstream for
any materials, such as packaging and applicators. days, weeks, months, or even years.
Gloves are then removed and hands are washed. ● Compared with a standard indwelling catheter, a
● Not all attempts to place an IV are successful; many CVAD is more durable and does not become as
fac- tors can cause a failure. easily blocked or infected. There are several kinds
○ For example, an attempt at puncture can of CVADs.
miss the vein. At this point, the needle ● They may contain one, two, or three lumens. Each
must be removed and properly disposed lumen has an independent catheter port so there is
of, the bleeding at the site must be no mixing of injected medications. Catheters may
stopped, the site must be bandaged, and a have an open end or closed end.
new vein proximal to the first attempt must ● Open-ended peripherally inserted central
be found. catheters (PICCs) must be clamped when not in
● Veins with multiple punctures should be avoided use.
because extravasation may occur through a prior ● Many manufacturers recommend that between uses
puncture site. they be flushed with a heparinized saline flush to
maintain the catheter's patency.
MANAGING PATIENTS WITH EXISTING VASCULAR ● Closed-end catheters contain a valve that controls
ACCESS
fluid flow and prevents reflux of blood into the
● Patients often arrive in the CT department with catheter. Closed-end catheters require only a saline
vascular access. In some cases the access will be flush to maintain patency.
via a standard indwelling peripheral venous
catheter, whereas others will arrive with a CVAD. In PERIPHERALLY INSERTED CENTRAL CATHETERS
either situation it is imperative that technologists ● A PICC is a long Catheter that is inserted through
follow basic rules to ensure the safe contrast the large veins of the upper arm (i.e., cephalic and
administration of a contrast agent. basilic veins) and advanced so that its tip is located
in the lower third of the SVC.
USING AN ESTABLISHED INDWELLING VENOUS
CATHETER ● PICCs are intended to provide central venous
access for several weeks, but can remain in
● When a patient arrives in the CT department with place as long as several months. They can be
an existing indwelling peripheral venous catheter, it either single or double lumen.
must be carefully evaluated before it can be used to ● A midline catheter is a similar, but considerably
administer a contrast agent. shorter, version that is placed so that it terminates in
An ideal IV access site for administering contrast the upper arm near the axilla.
media: ○ Because midline catheters do not extend
● 1) is well located (see "choosing the site" into the large central vein, they are
above), considered peripheral, not central
● 2) was established recently (older IV access catheters.
sites are more likely to extravasate), ○ The external appearance of a midline
● 3) contains a connecting hub or port that is catheter is often difficult to distinguish from
not accessed (i.e., an intermittent IV line), or if it a PICC. The type of catheter should be
is accessed, has a saline (0.9% sodium chloride) noted in the patient chart.
or a solution of 5% dextrose in water (D5W) ● Many PICC lines cannot tolerate the pressure
running, and required to inject contrast media (which is more
● 4) does not show evidence of redness, viscous than most intravenously administered
blanching, or swelling in the skin surrounding medications) at the high injection rates typical of CT
the puncture site. examinations that use mechanical injectors.
● In these cases it is recommended that a separate IV
be inserted for the administration of contrast media.
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● When no other options exist and the PICC must be ● The port is accessed by use of a special noncoring
used for contrast injection, the injection rate must hooked needle (also called Huber needles). If the
be slowed and the injection should be performed by access needle is not well placed in the reservoir,
hand bolus rather than by mechanical injector. fluid injected into it could extravasate into the
● In recent years specific PICC lines have been adjacent subcutaneous tissues.
designed to withstand up to 300 psi-more than ● Accessing and de-accessing an implanted port
enough for power injectors. requires special training and is beyond the scope of
● Many manufacturers produce these special PICC a CT technologist. However, once a port is properly
lines in colors that make them readily accessed it can be used for infusion.
distinguishable from the traditional PICC lines. Such ● No established guidelines exist for using CVCs for
is the case with the PowerPICC (Bard Access the mechanical infusion of contrast media.
Systems, Salt Lake City, UT), whose deep purple Therefore, whenever possible, a standard
color makes it easy to identify as a PICC line that peripheral IV access is preferred for contrast media
may be used to instill contrast media at rates up to injection. However, using central lines for injecting
5 mL/s by mechanical injector (Fig. 13-3). contrast medium may be the only option in some
● The practice for flushing PICCs after contrast cases.
administration is variable among facilities. To ● In general, most CVCs may be infused at rates of
maintain patency of the PICC and decrease the 1.5 to 2ml.
potential for occlusion, basaline, or a ● More rapid injection could potentially result in
combination of both. catheter perforation.
● When using power injectors with real-time pressure
A popular method for the PICCs and other CVADs is
monitoring capabilities, the operator should watch
the SASH method:
for any deviation from the pressure norms, which
● Saline flush,
could indicate possible occlusion or other adverse
● Administer medication or draw blood,
events related to catheters.
● Saline flush,
● When a CVC is used the technologist should
● Heparinized saline flush.
carefully examine the insertion site and report any
● However, practice will be different if the PICC drainage, oozing, redness, or swelling to the
contains a Luer-activated device. radiologist before injecting into the line.
● This is a needle-free TV system that is a saline-only ● Just as with any form of IV access, cleansing
device and does not require flushing with solution should be used to clean all junctions and
heparinized saline after infusion or blood sampling connections.
Technologists should become familiar with their ● All cleansing solutions should be allowed to
facility's written policy regarding PICC lines. completely dry to provide maximum disinfection.
The injection cap cannot be touched once it has
NON-TUNNELED AND TUNNELED CENTRAL VENOUS
been cleaned.
CATHETERS
● Only sterile devices or needles are used to
● Non- tunneled central catheters are a larger access CVADs.
caliber than PICCs because they are designed to ● Before administering any substance, the patency of
be inserted into a relatively large, more central vein a central line must be verified. This can be done by
such as the subclavian, jugular, or (less commonly) demonstrating blood aspiration.
a femoral vein. Non-tunneled catheters usually have ● The inability to aspirate blood can indicate catheter
three ports, are open ended, and typically remain in malposition or occlu-sion. To aspirate a central
place for a few days to 2 weeks. line, clean the injection cap and attach an empty
● Tunneled central venous catheters (CVCs) are 10-mL syringe.
inserted into the target vein (often the subclavian) ● Gently pull back on the plunger, just enough to see
by "tunneling" (under the skin. This reduces the risk blood, then flush with normal saline solution. If there
of infection, because bacteria from the skin surface is any doubt concerning the pat-ency of a CVC, do
are not able to travel directly into the vein. not inject into the catheter. If there is resistance to
● The tunneled catheter has a cuff that stimulates flushing a CVC, no further injection attempt should
tissue growth that will help hold it in place in the be made as doing so may cause the catheter to
body. rupture.
○ Examples of tunneled catheters include ● After injection the catheter should be flushed
Hickman, Broviac, and Groshong with 10 mL of normal saline. Close the slide
catheters. clamp while injecting the last 0.5 mL, of solution to
● The tunneled catheter is the best choice when ensure that the catheter will be full of flush solution
access to the vein is needed for long periods of and minimize the likelihood of blood backing up into
time and when the line will be used many times the catheter
each day. ● As with PICCs, institutions vary in their policies
○ It is secure and easy to access. regarding the use of CVCs for contrast medium
● Implantable ports consist of a single- or double- infusion. For example, some facilities prohibit the
lumen reservoir attached to a catheter. The use of ports for contrast infusion, whereas it is
reservoir hub is implanted in the arm or chest common practice in others.
subcutaneous tissue, and the catheter is tunneled ● The infusion of contrast media for CT using
to the accessed vein. No external device is visible. mechanical injectors through CVCs is feasible and
● The outline of the device may be seen and felt as a safe when established institution guidelines and
small round elevation on the skin. Implanted ports injection protocols are followed.
are typically used for long-term intermittent ● This provides an acceptable alternative in patients
access such as that required for chemotherapy. without adequate peripheral IV access when the
● Among central venous catheters, ports have the rapid injection of contrast media is needed.
lowest incidence of infection because they are
completely buried under the skin and there is no
site for microorganisms to enter.
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● There are also several types of large-bore

● CT angiography images are taken while
tunneled catheters used for dialysis. These
contrast is in the bolus phase.
should never be used for contrast media injection.
● Manufacturers label the external portion of
2. the nonequilibrium phase (venous phase)
catheters by putting in size and type on the catheter
● The second phase is the nonequilibrium
hub or external tubing.
phase. It follows the bolus phase and is
characterized by a difference of 10 to 30 HU
BASIC PRINCIPLES OF INTRAVENOUS CONTRAST AVID (Fig. 13-7).
ADMINISTRATION ● The contrast agent is still much brighter in the
arteries than in the parenchyma of organs, but
● The proper injection parameters are critical in
now the venous structures are also opacified.
many CT protocols.
● Hence, it is also called the venous phase.
● Injection parameters that must be considered
● This phase begins approximately 4 minutes
include the volume and concentration of
after the start of the bolus injection and lasts
contrast, the flow rate(s) at which the contrast will
only a short time, approximately 1 minute.
be delivered, programmed pressure limiting, and
● This window can be manipulated to some degree
the timing between the start of the injection and the
by varying conditions such as the volume and
start of scanning.
flow rate of the injected contrast medium.
● Documentation of intravenous contrast
● Most routine (nonangiographic) body images
administration is a legal necessity and should
are acquired while contrast is in the
include the name of the agent, the dose (volume
nonequilibrium phase.
and concentration), the flow rate(s), and the
injection site.
3. the equilibrium phase (delayed phase)
○ Any adverse effects and their
● The last phase of tissue enhancement after the
treatments must also be documented
IV injection of contrast media is known as the
(Chapter 12). When document-ing
equilibrium (or delayed) phase. It can begin as
information, technologists should use only
early as 2 minutes after the bolus phase or
approved abbreviations and forms, sign all
after a drip infusion.
documentation, and only record facts they
● In this phase, contrast media is largely
observed.
emptied from the arteries, 100 is greatly diluted
● Although the usefulness of IV contrast agents is
in the veins, and has soaked the organ
universally accepted, much controversy exists over
parenchyma In this phase, intravascular
the optimal method of administering contrast
structures and interstitial concentrations of
material.
contrast material equilibrate and decline at an
● The overarching goal is to select parameters that
equal rate.
will consistently improve images and will facilitate
● It is characterized by an attenuation
reproducible studies.
difference between the aorta and the inferior
● The latter is important because CT is often used for
vena cava of less than 10 HU (Fig. 13-8).
follow-up care and in cancer staging. It is difficult to
● The equilibrium phase is the worst phase for
determine whether a lesion has actually changed in
acquiring scans of the body, particularly the liver.
size (even if it appears so on the image) if the
● Compared with noncontrast examinations,
technical fac- tors used during scanning vary widely
visualization of tumors in the liver is improved in
from study to study.
both the bolus and nonequilibrium phases, but
● Improved image quality and the ability to
not in the equilibrium phase. In some instances
reproduce a study will ultimately lead to
scanning in the equilibrium phase is worse than
increases in disease detection and improved
simply scanning without IV contrast
diagnosis. Technologists should understand, at
enhancement.
least in broad terms, the issues that surround the
● Because in this phase contrast material
choice of injection parameters. To that end the
disperses more equally in the hepatic
discussion starts with a broad view of how contrast
parenchyma and the tumor's interstitial space,
media enhances tissues then moves to the more
the tumor can become isodense (i.e., the same
specific as we consider the route and pace of a
density as the surrounding tissue) and be
bolus injection of contrast medium as it travels
indistinguishable.
through the body.
● Therefore, scanning in the equilibrium phase
GENERAL PHASES OF TISSUE ENHANCEMENT does not improve visualization of hepatic tumor
compared with a precontrast examination and
Three general phases of tissue enhancement are carries a considerable risk of tumor
commonly discussed in CT: enhancement.
1. the bolus phase (arterial phase)
● The difference among these phases is
● The bolus phase is that which immediately
predominantly determined by the rate at which the
follows an IV bolus injection It is characterized by
contrast material is delivered and the time that
an attenuation difference of 30 or more
elapses from the start of the injection and when
Hounsfield units between the aorta and the
scanning is initiated. The phases are frequently
inferior vena cava.
compared by the arteriovenous iodine difference
● In the bolus phase of contrast enhancement, the
(AVID).
arterial structures are filled with contrast medium
● In practice this is done by comparing a Hounsfield
and brightly displayed on the image.
unit (HU) measurement taken within the aorta to
● Hence, this phase is also commonly called the
that of a measurement taken in the inferior vena
arterial phase. Contrast media has not yet filled
cava. The radiographic attenuation in HU serves as
the venous structures.
a surrogate measure of iodine concentration.

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● Historically, CT scan acquisition was much slower, triggering and timing a test bolus are often
making it impossible to obtain all scans through the incorporated into specific examination protocols.
liver before contrast media reached equilibrium. In The route that intravenously administered contrast
these situations liver lesions were often difficult, or medium takes from the site of injection to the
impossible, to detect with only the various target organs is quite long. Along the way is
contrast-enhanced study. a relatively predictable sequence of vascular and
● For this reason patients were often first scanned organ enhancement with various mixing processes.
without contrast enhancement through the liver, ● To mention just a few points along the way, the
then the entire abdomen was scanned after the contrast material flows from the injection site vein
injection of contrast media. into the vena cava, enters the right atrium, passes
● New scanners are much faster and all scans can the pulmonary circulation and finally arrives in the
easily be obtained before the equilibrium phase. As aorta.
a result, precontrast scans are now seldom needed ● Along the way to the right atrium the contrast mixes
for routine abdomen studies. with nonopacified blood. Once the agent reaches
the right ventricle, the mixing of opacified and
The exact timing of the start and end of each of the
nonopacified blood is complete.
three phases are affected by many factors, including:
● The contrast material enters the aorta during the
● injection parameters and
arterial phase, then passes through draining
● condition of the patient, particularly the
veins that either join the vena cava or enter the
patient's cardiac output.
portal venous system.
● The exact timing of the start and end of each of the ● Contrast material in the portal system enhances the
three phases are affected by many factors, liver parenchyma (the organ's tissue; as opposed to
including: the vascular structures) and drains into the liver
○ injection parameters and veins before it reaches the right atrium again.
○ the condition of the patient, particularly the ● As the contrast material flows back to the right heart
patient's cardiac output. from various organs, recirculation effects occur. It is
● In addition, the bolus and the nonequilibrium important to note that arrival time indicates when
phases are often further divided. contrast material is likely to first be present in the
○ The terms early arterial phase, late organ or vessel.
arterial phase, hepatic arterial phase, ● Therefore, arrival time represents the earliest
late hepatic arterial, portal venous possible time to acquire scans; images acquired
phase, hepatic venous phase, early before the contrast arrival times will appear
delayed hepatic phase, late delayed unenhanced.
hepatic phase, corticomedullary phase, ● Contrast enhancement typically reaches a
nephro- graphic phase, and excretory near-peak in the aorta from 15 to 22 seconds
phase can be found in the literature. after the start of the injection.
● Frequently the various terms are used ○ The time it takes to reach peak attenuation
inconsistently. is affected by the cardiac output of the
● Contrast material remains concentrated in patient.
organs and vessels for a very short time. ● As more contrast medium reaches the aorta, the
● Injection protocols are designed by first determining aortic enhancement rises only slightly more,
the time window from when contrast material is creating a type of plateau.
likely to first arrive in the organ or vessel of interest ● The peak aortic enhancement is reached at the
to when most of the contrast has vacated. end of this phase when all of the contrast has been
● Once this is estimated, equipment can be delivered, then drops off dramatically. The plateau
programmed so that scans are acquired within the can be extended by adding a saline flush, which will
window. push forward the contrast material left in the tubing
and in the veins leading to the aorta.
● Scanning within this enhancement plateau is ideal
for imaging the arteries. Because the true peak
enhancement point is short-lived (often <2
seconds), variable, and difficult to pre- dict,
scanning protocols are most often designed so that
images are acquired within the plateau (which
typically lasts 10 to 15 seconds) and not at the
peak.
● Most organs have an exclusively arterial blood
supply. The peak organ enhancement for such
organs (e.g., pancreas, bowel, bladder) occurs
about 5 to 15 seconds after peak aortic
enhancement.
● The kidneys are an exception because their
excretion of contrast medium must also be
considered. Kidney scans are often acquired in the
nephrographic phase, which is 80 to 120 seconds
after injection. This can be accomplished by
incorporating a slight scan delay between scans of
the liver and that of the kidney.
● The liver has a dual blood supply. It is supplied
primarily by the portal vein, contributing
● Because patient factors can significantly influence approximately 75%; the remainder is supplied by
the estimated window, tools such as bolus the hepatic artery. Although liver scanning is

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sometimes repeated to capture more than one

2. BOLUS TECHNIQUES
phase of contrast enhancement, at a minimum it ● The bolus technique of contrast enhancement
should be scanned in the portal venous phase. This uses scanning after a rapid injection of contrast
phase 2 occurs approximately 60 seconds after a material. A volume of contrast of 50 to 200 mL
bolus IV injec- tion and, by definition, includes both is injected at a rate (or combination of rates)
arterial and venous enhancement. between 1 and 6 mL/s; scanning begins after a
● Routine brain scanning (for metastases or primary short delay.
● The interval between the initiation of the injection
central nervous system tumors) provides a notable
and the start of scanning (the scan delay) is
exception to the general rules of contrast media critical.
injection. The enhancement of most brain lesions is ● The contrast bolus can be delivered by hand
caused by blood brain barrier disruption, not the (using syringes) or by a mechanical injection
intrinsic vascularity of the tissue. system
● Therefore, the injection rate is not important, and
scan delay is primarily important in that scans are
not performed too soon after injection. BOLUS TECHNIQUES
● A scan delay of 4 minutes or greater is typical to 1. Hand Bolus Technique
● When contrast media is injected by hand the flow
allow sufficient time for contrast to leak across
rate is subject to many factors, including:
a disrupted blood-brain barrier into the ○ syringe size,
abnormal tissue. However, nonroutine brain ○ contrast viscosity,
scanning such as CT angiography or CT brain ○ IV catheter size, and
perfusion studies require careful adherence to ○ operator strength.
contrast injection protocols. ● Smaller size syringes require less operator
strength to inject but must be serially
disconnected when empty and reattached with
replacement syringes.
● This delay will cause a drop in the peak
enhancement.
● Higher viscosity agents and smaller
indwelling catheters will require more operator
strength for injection.
● The advantages of the hand bolus method are
that it is relatively inexpensive and does not
require any special equipment to implement. In
addition, it allows the injection site to be closely
observed so that the injection can be
immediately stopped should there be signs of
extravasation of contrast into the soft tissue.
● As mentioned earlier, this is often the
recommended method for injecting into standard
PICC lines. However, there are many disad-
vantages to the hand bolus method: the operator
will be exposed to scatter radiation from standing
in the room during the scanning process, and
because someone must stay in the scan room
this method requires two operators.
● Probably the primary disadvantages are that
METHODS OF CONTRAST MEDIA DELIVERY the:
○ flow rate is variable because of the
factors mentioned earlier and
TWO METHODS OF ADMINISTERING CONTRAST ○ the scan delay cannot be precisely
MATERIAL: controlled;
1. DRIP INFUSION ● These two factors result in inconsistent images
● In the drip infusion technique, an IV line is that are not readily reproducible in subsequent
initiated and a contrast medium is allowed to drip studies. So although the hand bolus method is
in during a period of several minutes. an improvement over the drip infusion method,
● Scanning begins after most, or all, of the contrast significant disadvantages limit its use to special
agent is administered (roughly 2 to 3 minutes). circumstances.
Because this method relies on gravity the actual
flow rate delivered is quite variable and affected 2. Mechanical Injection Systems
by many factors (e.g., bottle height, contrast ● Mechanical injection systems are standard in CT
volume, tubing length, IV catheter size, contrast suites because they deliver the precise flow
media viscosity). rates and volumes specified by the operator,
● This variability prevents the injection from being regardless of the viscosity of the solution and the
uniformly reproduced in subsequent follow-up gauge of the indwelling catheter.
studies. This method is not recom- -mended for ● Injections are consistent and can be
scans of the neck, chest, abdomen, or pelvis reproduced in subsequent examinations
because all of the scans acquired with this (providing parameters from studies are properly
technique are taken in the equilibrium phase. recorded and repeated).
● The drip infusion method is the least effective ● In addition, mechanical injectors are
injection method for abdominal imaging, and programmable, providing broad clinical utility for
in some respects, is even inferior to scanning a wide range of indications.
without contrast enhancement. ● Mechanical injectors, or power injectors as
● The drip infusion method cannot produce peak they are frequently called, are made by a variety
enhancement of sufficient magnitude for CT of manufacturers, come in different models, and
angiography. offer various features.
● However, it can be used for routine brain ● CT injectors may have a single head for
scanning (for metastases or primary central affixing the syringe (Fig. 13-11A) or they may
nervous system tumors) because there is no accommodate two syringes (Fig. 13-11B).
need for a high injection rate and a scan delay of ● Dual-head injectors are designed so that saline
at least 4 minutes is typical can be given immediately before or after the
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contrast media injection. Most models of connection of the injector syringe and tubing. Air
mechanical injector include a programmable embolism can occur during any IV injection.
pressure limit. ● Small quantities of air can be absorbed by the
○ This allows the operator to set an upper body, so small air emboli may never be detected
pressure limit, along with an injection if patients are asymptomatic.
rate. ○ However, large air emboli can cause
● Contrast medium is then administered at the seizures, permanent neurological
selected rate, unless the pressure reaches the damage, or occasionally death.
maximum psi (pounds per square inch) set. If the ● These large air emboli occur only as a result of
pressure reaches the selected limit, the injector human error. Safeguards have been built into
reduces the flow rate to prevent exceeding the injection systems that are successful in
pressure limit and an alarm sounds to notify the preventing most errors of this type. When
operator. mistakes occur, they usually are a result of a
● Pressure limiting is designed to protect the disruption in the routine of preparing the injector.
integrity of the disposable components (e.g., IV ● At least one injector manufacturer has
tubing) used in the injection fluid path. Pressure incorporated automation to further reduce the
is a result of the force required to overcome the possibility of air emboli. Injectors with this feature
resistance of pushing the contrast from the will automatically retract the injector position
relatively large syringe barrel, through the patient when the syringe is removed, returning it to the
connector tubing, any ancillary devices, and home position, before a new syringe is attached.
ultimately the catheter, at the required flow rate. ● When a new, unused syringe is attached to the
● Pressure is greatest at the point where the injector, it will automatically drive the piston
largest diameter merges to a far smaller forward to the load position, thus always avoiding
diameter, in this case, the syringe tip. an empty syringe being in place on the injector
○ From that point to a point halfway down with the ability to inject air into the patient.
the length of the connecting tubing the ● In addition, some syringes contain visual
pressure will drop by half, whereas at indicators that provide clear and immediate
the tip of the catheter, pressure drops to indications as to whether a syringe contains fluid
near zero. or air.
● A common reason for reaching the pressure limit ● The exact process of preparing the injector
is when the IV tubing becomes kinked, restricting varies depending on the type of injection system,
the flow of contrast media. whether the facility uses prefilled syringes, and
● Another common culprit for reaching the the specific injection protocol. Therefore, each
pressure limit is the use of components in the facility should develop a clear protocol for
fluid path that are not compatible with power preparing the mechanical injector(s) used in that
injectors and the flow rates and pressures they department. The protocol should clearly specify
generate. the steps taken to prepare the injector for use.
● Another key factor in pressure limiting is ● In summary, the use of mechanical injectors
contrast viscosity. produces the best results. However, precautions
○ As mentioned previously, higher iodine must be taken to prevent contrast media
concentrations possess a higher extravasation and care must be taken in the
viscosity particularly at room preparation and connection of the injector and
temperature. Contrast viscosity can be cannula to avoid the risk of large air emboli
dramatically reduced, in some cases by
nearly half, by simply warming contrast
FACTORS AFFECTING CONTRAST ENHANCEMENT
to body temperature (37°C).
● Many factors affect the degree of contrast
● Another feature available on some models is a enhancement in human tissue. These factors can
device designed to aid in the detection of be broadly categorized as pharmacokinetic factors,
contrast medium extravasation.
which are largely controllable, and patient or
● Extravasation is the leakage of fluid from a vein
into the surrounding tissue during IV equipment factors, over which technolo- gists have
administration. little, or no, control.
● There is particular concern that mechanical
1. Pharmacokinetic Factors
injectors may increase the severity of
● include contrast medium characteristics (e.g.,
extravasation when extravasations occur.
iodine concentration, osmolality, viscosity),
Because mechanical injectors typically deliver
contrast media volume, flow rate, flow duration,
contrast at fast flow rates and the operator may
sean delay time, and total scan time
not remain in the examination room throughout
2. Contrast Media Characteristics
the injection to quickly intercede should signs of
● Although many concentrations are commercially
extravasation appear, there is worry that a large
available, most facilities use one concentra- tion
volume of contrast extravasation could more
for the majority of their CT examinations. Higher
readily occur when a mechanical injector is used.
concentration agents may be reserved for
○ However, when appropriate precautions
specialized stud- ies, such as CT angiography.
are taken, the risk of serious
● Contrast enhancement depends on the iodine
extravasation can be substantially
concentration in the vasculature or tissues.
reduced.
● In the vessels, this concentration depends on the
● The extravasation detection feature available on
injection rate of iodine in mg/s.
some injector models is designed to augment,
● Therefore, a concentration of 400 mg/mL
rather than supplant, such precautions.
injected at 3 mL/s will provide the same total
● Another potential safety feature available with
iodine as a con- centration of 300mg/mL injected
some power injectors is the ability to perform a
at 4mL/s. In spite of the relatively equal
saline test injection before the delivery of
enhancement they produce, there are
contrast bolus injections.
advantages and disadvantages associated with
● The saline may be programmed at the same flow
different concentration agents.
rate as the contrast bolus, thereby more closely
● To maintain the same vascular and organ
replicating an actual injection, and allowing the
enhance- ment, lower concentrations of contrast
technologist additional time to monitor the
medium require an increase in the injection rate
viability of an IV site.
and an increase in the volume (to maintain the
● Although it rarely occurs, when a mechanical
same iodine dose). When IV access is not ideal
injector is used, large air embolism can result
(e.g., small-gauge catheter in the back of the
from the incorrect preparation and inadequate

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The effects of varying these factors are more

hand), extravasation of contrast material is more
likely when a higher injection rate is used. In pronounced for aortic enhancement than for
addition, although uncom- mon, the increased hepatic enhancement.
contrast volume may impose an excessive ● The consequences of vary- ing contrast dose
volume load on some patients. This may be of (determined by contrast volume and concentration)
concern in the rare instance when users make and flow rate can be graphically depicted using a
their own dilutions by adding saline solution or time-density curve.
injectable distilled water to contrast media.
● The z axis of the graph depicts the time elapsed (in
Excessive dilution of contrast media with distilled
water may produce hypotonic solutions, with an seconds) after the start of injection, whereas the y
associated risk to the patient of edema." axis charts the relative enhancement levels
● Lower concentrations of contrast medium achieved, in Hounsfield units (Figs. 13-14 through
have the advantage of possessing slightly 13-17).
lower osmolality, which is associated with fewer ● Computer simulations and porcine models help to
adverse effects. Theoretically, lower isolate the consequences of varying specific
concentration solutions will produce fewer high-
injection parameters. The time-density curves
contrast (streak) artifacts in the injected vein.
This is particularly important in the chest where included in this section are intended to illustrate
streak artifacts are often created by dense the relationship between contrast media dose,
contrast in the central veins (Fig. 13-12). Some injection flow rate, scan delay, and scan
power injectors offer the ability to inject contrast duration
and saline simultaneously as a means of ● For a constant volume and concentration of
decreasing streak artifacts and optimizing image contrast media, as the flow rate is increased,
quality, while still delivering high-density contrast
to the area of diagnostic interest. there is a decrease in the time to peak aortic
● In comparison, injecting a higher concentration enhancement.
agent (2350 mg iodine/mL) will deliver the same ● In practice, this means that the scan delay must be
amount of iodine at a lower flow rate. The same adjusted according to flow rate. For a constant
or higher flow rate provides a concentrated bolus volume of contrast media, increasing the flow rate
that is well suited for examinations with a short shortens the duration of the contrast injection.
scan duration (e.g., CT angiography), particularly
● It should be clear that to capture optimal vascular
when multislice scanners are used.
● The viscosity of a contrast agent increases enhancement for CT angiography studies, the scan
with its iodine concentration. timing must be precise.
● Prewarming of the contrast material to body ● Image acquisition that is too soon will miss the
temperature can help to reduce the viscosity so contrast bolus, whereas scanning too late may not
that it can flow more easily through indwelling IV provide adequate opacification, particularly of small
catheters. vessels.
● The value of a saline flush is increased when
● Manipulating the flow rate during an injection can
higher concentration agents are used because
the more viscous contrast material will remain improve the likelihood of scanning during optimal
longer in the venous injection path. vascular enhancement. Manipulating the flow rate
to change the characteristics of the time-density
curves is sometimes called "bolus shaping."
● The typical time-density curve for aortic
enhancement using a single injection flow rate (uni-
phasic), such as that depicted by the black line in
the graph in Figure 13-15, is not ideal for CT
angiography.
● A uniphasic injection results in a single peak of
aortic enhancement that is generally much greater
than necessary, but of a very short duration. Ideally,
injection techniques would achieve an adequate
level of aortic enhancement and then maintain that
Contrast Media Volume, Flow Duration, Flow Rate
level for a longer period of time, depicted by the
● As scanner technology evolved from axial scanning
blue line in the graph in Figure 13-15.
to SDCT to MDCT, scan duration has dramatically
● This would increase the window of opportunity
decreased.
for scanning, allowing the scan timing to be less
● This increased speed has had an impact on the
precise.
volume of contrast media used for typical CT
● This is particularly useful when using a slower
studies.
scanner, when using very narrow collimation, or
● When scanners were slower, a larger volume of
when scanning a longer area.
injected contrast served to extend the flow duration
● In addition, more uniform vascular enhancement is
and expand the window of opportunity for acquiring
beneficial for postprocessing. In practice, bolus
scans while tissues were optimally enhanced.
shaping is accomplished by beginning the injection
● Shorter acquisition times often allow the
with a relatively high flow rate and then decreasing
contrast volume to be reduced. The degree to
the flow rate throughout the remainder of the
which contrast volume can be decreased depends
injection period.
on the study, however. Whether, and how much,
● When two flow rates are used the technique is often
contrast volume can be cut during liver imaging is
referred to as biphasic; when more than two flow
controversial.
rates are used the technique is referred to as
● A certain amount of iodine is needed to achieve
multiphasic.
adequate parenchymal enhancement; dropping
● Often the final flow rate is to deliver a saline flush.
below that volume will reduce lesion conspicuity.
This allows the entire volume of contrast media to
● The rate that contrast media is injected largely
be used as the saline pushes forward any contrast
determines the time needed for it to reach peak
that remains in the injection veins. In some
enhancement and will influence how dramatically
instances bolus shaping can allow a reduction in
enhancement falls off once this peak is reached.
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contrast volume. This is possible when it is used ● For instance, the scan duration is considerably less
with a fast scanner or when the scan area is for a 64-detector row scanner than for a
relatively limited. single-detector row scanner.
● However, for most clinical applications a ● As a general rule, the scan delay is increased as
uniphasic contrast injection with a constant scan duration decreases. Adding 5 to 20 seconds to
flow rate is sufficient. the scan delay helps to ensure imaging occurs
● Although considerably less pronounced, many of during peak arterial enhancement. In this way, it is
the same principles apply to hepatic enhancement possible to keep all other contrast injection
(Figs. 13-13B and 13-14B). parameters constant, thereby achieving the same
● That is, increasing the dose will increase the aortic enhancement curves, by simply adjusting the
magnitude of the hepatic enhancement and scan delay according to scanner speed.
increasing the flow rate will shorten the time to peak ● For some applications, a faster scanner may allow
enhancement. the use of a smaller volume of contrast material.
● However, compared with aortic enhancement the As stated previously, when the volume is
slope of the contrast-timing curves for hepatic decreased, the peak enhancement level decreases
enhancement is less steep with a longer horizontal (Fig. 13-13). Therefore, injection rate or iodine
portion during which contrast enhancement remains concentration is typically increased to compensate
relatively constant.
AUTOMATED INJECTION TRIGGERING
● In practice this allows a wider window of opportunity ● Two methods exist for individualizing the
for scanning; therefore, the timing of scans for scan delay:
routine abdominal imaging does not need to be as ○ the injection of a test bolus and
precise as those designed to capture peak aortic ○ bolus triggering.
enhancement ● Both techniques require the CT scanner to have
specialized software.
PATIENT FACTORS AFFECTING CONTRAST ● These methods are particularly useful for
ENHANCEMENT vascular imaging, in which it is criti- cal that the
timing of scan acquisition coincide with peak
● Many patient factors have important effects on
contrast enhancement.
contrast enhancement. These include the patient's ● These methods effectively accommodate
age, sex, weight, height, cardiovascular status, individual differences in circulation time
renal function, and the presence of other caused by heart rate, age, and illnesses
diseases. Although patient factors are largely
uncontrollable, it is important to recognize their TEST BOLUS
potential effects on contrast enhancement. In some ● This method consists of administering 10 to 20
cases injection parameters can be adjusted to help mL of contrast medium by IV bolus injection and
mitigate patient factors. performing several trial scans to determine the
● The patient's weight has a pronounced effect on the length of time from injection to peak contrast
enhancement in a target region, such as the
degree of aortic and parenchymal enhancement.
aorta.
Figure 13-16 displays a time-density curve for each ● Using a mechanical injector, the test injection
of a number of simulations of patients with different is delivered at the same rate as the diagnostic
body weight, when all other factors are held scans.
constant." Notice that although peak enhancement ● Trial scans are taken using the lowest
is reached at nearly identical times, as patient possible mAs settings, typically at 2-second
weight increases the magnitude of contrast intervals, at the same slice location, for 20 to 30
seconds (i.e., 10 to 15 scans).
enhancement diminishes. In large patients arterial ● Trial scans begin from 8 to 15 seconds after the
enhancement can be increased by increasing the start of the injection, depending on the patient's
injection rate (by either increasing the flow rate or presumed circulatory status.
increasing the iodine concentration). Because ● Hence, trial scans of younger patients with no
hepatic parenchymal enhancement is determined history of heart disease would begin 8 seconds
primarily by the total iodine dose, increasing the after the start of the injection, whereas the trial
scan of an older patient with known congestive
dose can also improve hepatic enhancement in
heart failure requires a longer delay.
large patients. For this reason, some insti- tutions ● The test bolus is evaluated by identifying the
used a weight-based system for determining the image that shows the maximum enhancement in
contrast media dose for routine body scans. the target region. The optimal scan delay time for
● A patient's cardiac output status can have a the actual study is presumed to be equal to the
significant effect on the time it takes injected time that elapsed from the start of the test
contrast media to reach peak aortic enhancement. injection to that of the image showing maximum
enhancement.
As cardiac output is reduced, there is a
● Experience shows that the best results are
progressively longer delay in the time required for achieved by adding 3 seconds to this calculated
the contrast bolus to reach the aorta, thus delaying delay. Therefore, when the test injection images
peak aortic enhancement (Fig. 13-17). are obtained every 2 seconds, scan time can be
● This requires the scan delay to be extended in calculated from the test injection using the
proportion to the degree of cardiac impairment; following: trial scan delay + (2x the image
practically, this can only be done by using a method showing maximum enhancement) + 3
seconds.
(i.e., test bolus, or bolus-tracking) that individualizes ● Special test bolus software helps to simplify the
the scan delay to the patient. process by graphing the time of the trial injection
against the level of contrast enhancement
EQUIPMENT FACTORS AFFECTING CONTRAST
ENCHANCEMENT
BOLUS TRIGGERING
● Contrast administration and scan timing must ● This method of individualizing the scan delay is
also be modified according to the type and called bolus-triggering, bolus-tracking, or
capabilities of the CT scanner used. automated triggering.
● It is a more efficient method than the test bolus

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○ The hardened x-ray beam presents a false

because it uses the contrast bolus itself to initiate
the scan. low linear attenuation coefficient and false
● This technique uses a series of low-radiation low CT number.
scans to monitor the progress of the contrast ○ When an object (calcification) is not fully
bolus. within a slice thickness, the CT number
● To accomplish this, a single cross-sectional slice representing that object will be false.
is taken and an area of interest is defined. The 4. Partial volume artifacts can be reduced by
injection is initiated, and low-radiation scans
overlapping scans but that increases patient dose
begin from 8 to 10 seconds later.
● These scans are sometimes referred to as ○ Partial volume artifacts can be reduced by
"monitor scans." using thinner slice thickness but at the
● Once an adequate level of enhancement is expense of higher image noise and/or
achieved (determined visually or by a cursor patient dose.
placed on the area of interest), the table moves ○ Partial volume artifacts can be reduced in
to the starting level and scanning begins. spiral CT by moving the plane of
Scanning can be triggered automatically by
reconstruction.
setting a predetermined threshold CT number or
it can be initiated manually by the technologist ○ Multiple reconstruction along the z-axis
● Because the table must move to the correct during spiral CT reduces partial volume
position and the mAs be set to the appropriate artifacts
level for diagnostic scanning, there is a 3- to ○ Partial volume artifacts can be reduced by
9-second delay between the last monitor scan combining several thin slice reconstructed
and the start of scanning. This lag time is seen images.
by many as a significant drawback to the
technique. Recognizing the delay, many facilities 5. Ring artifacts can occur in third-generation CT
use a relatively low trigger threshold imagers because of detector multifunction
(approximately 50 HU) or manually start the scan 6. Pulsation artifacts are observed in CTA.
as soon as the contrast material is seen in the ○ Pulsation artifacts can simulate vascular
target region. stenosis.
● An important drawback to bolus triggering is that ○ Pulsation artifacts can be reduced by using
a technologist cannot stay with the patient for
360° interpolation rather than 180°
even a short time after the contrast injection
begins or they will be exposed to radiation from interpolation.
the monitor scans. The policy at many facilities is 7. The stair-step artifact is associated with spiral CT.
for the technologist to remain with the patient for ○ The stair-step artifact is most apparent on
the first few seconds of the injection to watch for inclined vessels during spiral CTA.
extravasation by manually palpating the injec- ○ The height of a stair step artifact is
tion. Although a test injection with saline before proportional to couch increment.
the scan can help to verify the patency of the IV
○ The height of a stair-step artifact is
line, sometimes extravasation will still occur
during the contrast injection. independent of collimation or
● For this reason, bolus tracking is typically reconstruction interval
reserved for vascular imaging but not for
routine examinations of the chest or
abdomen, for which timing is not as critical. For
routine studies, most facilities rely on preset scan
delays.
● With some newer, more advanced injector
systems, many of the above strategies and
calculations for designing patient-specific
protocols are being calculated by the injector. At
least one injector manufacturer now has built-in
software that accounts for patient variation in
weight, time to peak, scan duration, and contrast
iodine concentration and can prescribe an
individualized injection protocol designed to
optimize enhancement. Further developments
will, no doubt, be forthcoming in this area.

ARTIFACTS
1. Voluntary and involuntary patient motion can
result in a motion artifact.
○ The motion artifact appears as streaks or
step-like patterns at high contrast edges.
○ Respiratory motion artifacts in computed
tomography angiography (CTA) can
simulate vascular stenosis or aneurysm.
2. Metal artifacts occur because the x-ray absorp-
tion results in incomplete projection profiles.
○ Metal in tissue gives rise to streak and
star- shaped artifacts.
3. The beam-hardening artifact appears as a dark
ring inside cranial bone and cupping at the center of
the image.
○ With penetration of cranial bone, the x-ray
beam is selectively filtered and
"hardened."

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